Keywords
VaginoplastyVaginal colporraphiesCombined colporraphies and perineoplastyVaginal tighteningAesthetic vaginal plastic surgeryVaginal rejuvenation
Tighten the entrance; increase vaginal wall tone
Many women, especially after having children, declare not being interested in having sex anymore, which is due to the fact that they don’t feel the same. Nowadays we have a solution for these women! They deserve to enjoy life, to lead in their sexuality, and we can offer them with a vaginal rejuvenation procedure that will include anterior and posterior vaginoplasty plus perineoplasty.
Although the term surgical vaginal tightening is used for all of the possible surgical alternatives that help enhancing sexual gratification to both male and female, vaginal tightening as a term does not describe a procedure intended for it.
As we’ve established in this book, sexual gratification is different between male and female. Leaving a tight or narrower vagina will not necessarily be the answer for women, as it may be painful during intercourse. To them it’s more important being able to contract vaginal walls with more energy and strength when having sex. With that in mind, the purpose of a surgery should be to give vaginal walls a better tone, and not only tighten the canal itself.
By combining anterior and posterior vaginoplasty procedures with a perineoplasty, patients will be able to contract vaginal walls better, thus enhancing both female and male sexual gratification .
Anatomy
The vagina is a canal-like structure that communicates the outside with the uterus cervix, measuring 6–12 cm long which varies from patient to patient. After a hysterectomy this canal can end up being shorter.
Vaginal walls are 2–4 mm long, and although very thin, they have several distinctive histological layers: mucosa, lamina propria (loose connective tissue), fascia, vaginalis muscularis (smooth muscle), and adventitia (located behind muscularis is an extension of endopelvic fascia). Anteriorly, fascia is known as pubo-cervical fascia while posteriorly is known as rectovaginal fascia.
Seen upwards, the vagina is attached to cervical ring and downwards to the hymenal ring. Ligaments and muscles help it keep its shape and axis. The adventitia forms a netlike structure providing vagina with lateral support.
Assessment: Combination of Anterior and Posterior Vaginoplasty and Perineoplasty
Important Fact
Listen to patient carefully and ask the right questions: you can get to a diagnosis even without examining her.
It is very important to understand why is the patient seeking a vaginal tightening . Listen to her carefully before even examining her; if you ask the right questions, you will have your diagnosis.
Vaginoplasty
Perineoplasty
Perineoplasty and vaginoplasty
Anterior vaginoplasty
What Will the Patient Tell Me?
“I do not like my vagina, it looks wide open!”
“The skin of my vagina seems to get thinner and thinner.”
“My vagina skin keeps getting dryer.”
“When I check at myself down there I find some pinkish tissue showing through and I do not like it!”
“I do not like seeing the inside of my vagina.”
“My labia were trimmed way too much during labiaplasty, so I can see the inside of my vagina.”
“My labia were trimmed way too much during labiaplasty years ago, and now I’m experiencing dryness.”
“When I gave birth I teared down there, I’m afraid they didn’t suture correctly.”
“I have an awful scar down there.”
“I have excess tissue down there; I don’t like it!”
“I need for you to remove those sort of folds in my perineum that go all the way up to my anus.”
“Some urine drops off when I jump or cough and I hate it!”
“After having kids, intimacy just doesn’t feel the same.”
“Sometimes I pee myself and its becoming more frequent.”
“I love going to the gym, but I hate getting wet down there during weight lifting!”
“I love the gym, but I hate getting wet down there during Zumba/Aerobics, can you fix me?”
“I just wish I could go back to feeling the way I used to.”
“Sex just isn’t appealing anymore.”
“I do not know what’s wrong with me. I’m frigid!”
“I used to feel more with my vagina , but now it is totally numb, I feel nothing down there!”
“What is the point of sex if I just don’t feel anything!?”
“Trying to get an orgasm has been really difficult to me for some time now, I’ve had to find other ways to help myself, with other sorts of stimulation to achieve it.”
“Could you examine me to see if I am a good candidate for vaginal tightening.”
“I just want an improvement down there!”
Her sexual life concerns related to her partner.
“I’m running out of excuses, I just do not want to have sex with my husband anymore!”
“It’s just embarrassing! Sometimes, while having sex, there’s this sound as though air enters my vagina during intercourse.”
“I am afraid my husband will leave me and find another woman, I just do not want to have sex with him anymore, cause, neither of us enjoys sex like we used to!”
“I know I don’t please him as before, but he won’t tell me, I want to surprise him!”
“I think my husband is less interested in me.”
“Our marriage is not doing well, so maybe if sex improves we may still have a chance!”
“We just don’t feel the same after our kids were born. Sex was very important for us, but now we’re less interested in it every day!”
“We have discussed the situation and are willing to try getting our sex life back, by trying some kind of vaginal tightening procedure!”
What her partner tells her:
“It feels terrible being in the middle of sex and have him tell me: “Tighten your vagina,” nothing like that ever happened before the children!”
“My husband says it doesn’t feel the same anymore after the kids. I want this fixed!”
“I know my vagina is not as tight as it used to, I confirmed it when he asked me to tighten more during the sex.”
“My husband suggested this surgery, he was the one who got me the appointment.”
“Could you please fix my wife?”
What to Look for in My Patient?
Important Fact
In order to help increase both male and female sexual gratification, several vaginal tightening surgical techniques must be done at the same time.
After listening to your patient, you will have a clearer understanding of why she’s there. If patient’s medical history shows her and her partner referring a decrease in sexual gratification, then more than one surgical approaches for vaginal tightening must be addressed. Performing only perineoplasty or anterior or posterior vaginoplasty may not solve the problem for both.
Ask if she suffers from stress incontinence, and if so, be alert for it during internal vaginal examination, having the patient push once in lithotomy position.
How to Ask for Stress Incontinence
When you jump or sneeze, do you feel you wet your underwear, even a little bit?
Does it happen frequently or eventually?
First
Ask again what bothers her, and, if possible, have her show you, and then take a good look again.
Second
Have her push and check the vaginal introitus; if there is anterior or posterior prolapse, you will notice it.
Third
Perineal area, look for:
Excess mucosa, mucosa/skin folds.
Visible scarring tissue, feel it and see if it hurts when touched.
Small lacerations on perineal area.
Small lacerations on vaginal introitus.
Exposed inner vagina mucosa.
Vaginal internal exam, look for:
Hard inelastic scar tissue
Loose muscle tone at the entrance
Loose muscle tone anteriorly inside vaginal walls
Good anterior vaginoplasty candidate
Loose muscle tone posteriorly inside vaginal walls
Good posterior vaginoplasty candidate
Loose muscle tone both at vaginal entrance and inside it
Good candidate for both perineoplasty and vaginoplasty
What Can Perineoplasty Plus Vaginoplasty Achieve?
Advantages
Ideal when there’s muscle diastasis of perineal muscles plus loose vaginal entrance and also inside vaginal walls during internal examination
Can be done together with labiaplasty to enhance the whole vaginal area
Helps reduce outer introitus or vaginal entrance
Helps bring labia minora together on midline
Reduces evidence of inner vaginal mucosa
Improves both female and male sexual gratification
Disadvantages
It won’t be sufficient if the main concern is to enhance female’ sexual gratification.
May end up too tight making intercourse painful to women, as there will be pressure on scar tissue.
Could leave a painful scar.
Dehiscence is not uncommon.
If dehiscence occurs, there is a high risk of having a painful scar.
If overcorrected, lacerations can occur on perineal area during intercourse.
Important Fact
Never overcorrect it; if it ends up in a smaller inner than outer introitus, the patient will suffer lacerations during intercourse.
Presurgical Exams
Blood tests
Hemogram
PT and PTT
Creatinine
Other, according to medical records
Urine test
Urine culture
Vaginal smear
Cytology (uterine cervix)
Surgery Plan
Patient’s Posture During Procedure
Patient must be in lithotomy position to facilitate access to surgeon during the procedure.
Anesthesia
Important fact
General anesthesia only can be used, but a pudendal block will help with after-procedure analgesia.
Pudendal block (for postsurgical anesthesia)
Use a pudendal block kit.
If no pudendal block available, a Spinocath catheter can be used for easier needle injection.
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